A nurse receives a report on a client with a basilar skull fracture. What findings should the nurse expect with this client?

Bruising over the mastoid process

Pooling of blood and edema around the eyes

Ability to recall how the injury occurred

Chvostek’s sign

Answer and Explanation

The Correct Answer is A

Choice A rationale
Bruising over the mastoid process, also known as Battle’s sign, is a classic clinical sign of a basilar skull fracture.
Choice B rationale
Pooling of blood and edema around the eyes, or ‘raccoon eyes’, is another sign of a basilar skull fracture.
Choice C rationale
The ability to recall how the injury occurred is not directly related to the presence of a basilar skull fracture. Memory loss or confusion could be symptoms of a traumatic brain injury, but they are not specific to a basilar skull fracture.
Choice D rationale
Chvostek’s sign is a clinical sign of hypocalcemia, not a basilar skull fracture

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Correct Answer is B

Explanation

Choice A rationale
Pulmonary embolus is a serious condition that can occur due to prolonged immobility, but it is not directly related to the timing of enteral nutrition in a client with increased intracranial pressure.

Choice B rationale
Bacterial translocation refers to the migration of bacteria from the gut to other areas of the body. Early enteral nutrition (within 24 to 48 hours) in critically ill patients can help maintain the integrity of the gut mucosa and prevent bacterial translocation. Therefore, starting enteral nutrition within this timeframe can help prevent bacterial translocation.
Choice C rationale
Deep vein thrombosis, like pulmonary embolus, is a risk due to immobility but is not directly related to the timing of enteral nutrition.
Choice D rationale
Myocardial infarction is a cardiac event that could be related to overall cardiovascular health, stress, or specific injury to the cardiac muscle. It is not directly prevented by the initiation of enteral nutrition.

A. Patient is confused B. Patient mumbles inappropriate words C. Eyes do not open to name

Correct Answer is A

Explanation

Choice A rationale
A patient in the intensive care unit who was admitted with severe head trauma and cerebral edema, who opens their eyes spontaneously, is oriented, and obeys commands, would be experiencing a decline in their condition if they become confused. Confusion can be a sign of worsening brain function, indicating that the brain is not receiving enough oxygen or is being affected by a buildup of toxins. This could be due to increased intracranial pressure, decreased blood flow to the brain, or further injury to the brain tissue.
Choice B rationale

Mumbling inappropriate words can also be a sign of a decline in a patient’s condition. However, it is less specific than confusion. It could be due to a variety of factors, including medication side effects, sleep deprivation, or mental health issues.
Choice C rationale
If a patient’s eyes do not open to their name, it could indicate a significant decline in their condition. However, this is a more severe symptom than confusion and may not be the first sign of a decline.

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A nurse receives a report on a client with a basilar skull fracture. What findings should the nurse expect with this client?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is planning care for a client who has increased intracranial pressure. The nurse should understand that enteral nutrition should begin within 24 to 48 hr to help prevent which of the following complications?

Correct Answer is B

Explanation

A nurse is caring for a patient in the intensive care unit who was admitted with severe head trauma and cerebral edema. The patient opens their eyes spontaneously, is oriented, and obeys commands.Which of the following findings indicate the patient is experiencing a decline in their condition?

Correct Answer is A

Explanation

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